Affidavit Of Indigency Form printable pdf download

Commonwealth of Massachusetts

AFFIDAVIT OF INDIGENCY

AND REQUEST FOR WAIVER, SUBSTITUTION

OR STATE PAYMENT OF FEES & COSTS

(Note: If you are currently confined in a prison or jail and are not seeking immediate release under G.L. c. 248 §1, but

you are suing correctional staff and wish to request court payment of “normal” fees (for initial filing and service), do not

use this form. Obtain separate forms from the clerk.)

______________________________

__________________________________________________________

Court

Case Name and Number (if known)

Name of applicant

Address

(Street and number)

(City or town)

(State and Zip)

SECTION 1:

Under the provisions of General Laws, Chapter 261, Sections 27A-27G, I swear (or affirm) as follows:

I AM INDIGENT in that (check only one):

(A) I receive public assistance under Transitional Aid to Families with Dependent Children (TAFDC).

Emergency Aid to Elderly, Disabled or Children (EAEDC), Supplemental Security Income (SSI), Medicaid

(MassHealth) or Massachusetts Veterans Benefits Programs; (circle form of public assistance received); or

(B) My income, less taxes deducted from my pay, is $_____________ per week/month/year (circle period that

applies), for a household of ______ persons, consisting of myself and _____ dependents; which income is at

or below the court system's poverty level; (Note: The court system's poverty levels for households of various

sizes must be posted in this courthouse. If you cannot find it, ask the clerk. The court system’s poverty level

is updated each year.) [List any other available household income for the circled period on this line:

_____________) or

(C)

I am unable to pay the fees and costs of this proceeding, or I am unable to do so without depriving myself

or my dependents of the necessities of life, including food, shelter and clothing.

IF YOU CHECKED (C), YOU MUST ALSO COMPLETE THE SUPPLEMENT TO THE AFFIDAVIT OF

INDIGENCY.

SECTION 2:

(Note: In completing this form, please be as specific as possible as to fees and costs known at the time of

filing this request. A supplementary request may be filed at a later time, if necessary.)

I request that the following NORMAL FEES AND COSTS be waived (not charged) by the court, or

paid by the state, or that the court order that a document, service or object be substituted at no cost (or a

lower cost, paid for by the state): (Check all that apply and, in any "$____" blank, indicate your best

guess as to the cost, if known.)

Filing fee and any surcharge. $ _____________

Filing fee and any surcharge for appeal. $ _______________

Fees or costs for serving court summons, witness subpoenas or other court papers. $______________

Affidavit Of Indigency Form